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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t. FOR OFFICE USE: „ E APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) _ <br /> _ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made-in compliance with San Joaquin Cou y Ordinrce No. 1862 and the rules and regulations of the San Joaquin�ocal Health District. <br /> + <br /> I Exact Site Address S Lo a City/Town 1—r4--L CL, _ - <br /> Owner's Named =# � Phone <br /> Address City f^re.1�t <br /> , Caun s5 <br /> Contractor's Name o C1C+fG ��.I License#3 ��Z.1 3 Business Phone <br /> r $ <br /> Contractor's Address 06 -1 C-- '` Emergency Phone `t ' <br /> ` A No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4 <br /> TYP90F WORK (CHECK): NEIN WELT_❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ F <br /> WELD CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> 4 <br /> REPLACEMENTS. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> — <br /> Property <br /> Property Line Private Domestic Well Public Domestic Well t, <br /> USE I' TYPE OF WELL <br /> i <br /> � ❑ ADUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> F DOMESTIC/PRIVATE ❑ DRILLED Dia. of Wel! Casing <br /> ❑ pt?MESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor IN 00SC.1 <br /> Type of Pump S H.P. <br /> PUMP REPLACEMENT: State Work Done �'""` 6, <br /> ' PUMP REPAIR: II ❑ State Work Done <br /> ` �o Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter pp .', <br /> is <br /> Describe Materia! and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,'and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> sued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Co or's hiring r iub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> l i� p it is issued, I haul employ persons subject to workman's compensation laws of California." <br /> w I al t Inspectio prior to grouting and a final inspec wn. <br /> Slg d <br /> Title: 1� Date: <br /> {Draw Plot Plan on Reverse Side} <br /> FOR DEPARTMENT USE.ONLY <br /> PHASE 1 <br /> Application Accepted By AV-e Date1-22— —V) <br /> Additional Comments: <br /> I Phase II Grout Inspection P se I Fina 1pection <br /> fInspection By Date N-0'1 Inspection By Date <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> c BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> . DATE DATE REWTTED AMOUNT - <br /> FEE 4�'``fes -I 1�' X, <br /> LESS <br /> PRORATION j;- <br /> PLUS PLUS r <br /> PENALTY I' <br /> hi OTHER <br /> Y OTHER <br /> /12421 -;Z2 <br /> Received by ,: Date - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 9520.1 <br />